Medicare Part A will only cover emergency room visits if the beneficiary is admitted to the hospital as an inpatient for the same illness that prompted their trip to the emergency room. This means that, in most cases, Medicare will not cover an emergency room visit.
Original Medicare consists of two parts — Part A and Part B.
In short, Part A is hospital insurance, Part B is medical insurance. Medicare has expanded, and now includes additional parts, such as Part C (Medicare Advantage), and Part D which is designed to help with prescription drug costs.
What Medicare Parts Cover Emergency Room Visits?
Medicare Part B is the only part of Medicare that will cover ER visits, and it’s important to note that this doesn’t mean full coverage. In other words, you’ll still be responsible for a certain percentage of all associated fees based on your coinsurance, which is your share of the medical expenses after your deductible has been met.
Medicare Part B
Medicare Part B’s main purpose is to provide medical coverage for beneficiaries. Part B usually pays for emergency room visits so long as the reason for going to the emergency room is that you’ve experienced:
- An injury
- A sudden illness
- An illness that has rapidly gotten worse
Medicare Advantage (Part C)
Medicare Advantage is an alternative to Original Medicare, and many plans are HMOs or PPOs. Each plan comes bundled with Part A, Part B, and usually Part D, and is purchased through private insurance companies approved by Medicare.
Medicare Part D
• HIV/AIDS treatments
• Antipsychotic medications
• Anticonvulsive treatments for seizure disorders
• Anticancer drugs (unless covered by Part B)
Medigap does not cover the cost of emergency room visits; its purpose is to help Medicare beneficiaries pay for some out-of-pocket expenses. A Medigap policy is supplemental insurance and does not provide additional coverage.
Medigap is sold by private insurers, so the type of coverage provided and its cost can vary depending on many factors.
What Medigap Covers
Part A (Hospital Insurance)
- Coinsurance and hospital fees
- Hospice coinsurance, or copayment costs
*Depends on the type of plan and/or provider
Part B (Medical Insurance)
- Coinsurance, or copayment costs
- Deductible, excess charges**
- Emergency medical costs during foreign travel
**Depends on the type of plan and/or provider
Medigap Will Not Cover:
- Prescription drugs
- Vision, dental, or hearing care
- “Health Perks” such as fitness memberships, transportation services, etc.
How Much Does An Emergency Room Visit Cost?
In 2019, the average price for an emergency room visit was $1,055. For those with health insurance, the average out-of-pocket payment was $275. One reason why an ER visit is so costly is due to higher severity services.
Between 2012 and 2019, high severity visits to the ER increased by 13%. The higher the severity, the more expensive the visit is. Below is a table of the Emergency Severity Index (ESI) that shows the five different levels of severity.
|1||Life-saving intervention needed immediately||Cardiac arrest; Massive blood loss|
|2||Time-critical problem||Cardiac-related chest pain; Asthma attack|
|3||Stable, multiple types of resources required||High fever with cough; abdominal pain|
|4||Stable, one type of resource required||Simple laceration; pain on urination|
|5||Stable, no anticipated resources required||Rash; Prescription refill|